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Provider Newsletterhttps://providers.amerigroup.com/��
February 2019DC-NL-0116-19
February 2019
Table of ContentsCoding spotlight: diabetes — provider guide to coding the diagnosis and treatment of diabetes
Page 2
Wellness center Page 2
My Diverse Patients — a website to support your diverse patients Page 3
Medical Policies and Clinical Utilization Management Guidelines update
Page 4
New specialty pharmacy medical step therapy requirements Page 5
Introducing a new clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit
Page 5
Medical necessity review for appropriate level of care Page 6
New Mother Postpartum Visit Schedule Page 7
Access patient-specific drug benefit information through electronic medical records
Page 7
Physical and occupational therapy reviews Page 8
Prior Preterm Pregnancy Program Page 9
Prior authorization update for 17 Alpha-hydroxyprogesterone caproate/Makena
Page 9
Reimbursement Policy:Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Page 10
Page 2 of 10
Coding spotlight: diabetes — provider guide to coding the diagnosis and treatment of diabetes
Diabetes mellitus is a chronic disorder caused by either an absolute decrease in the amount of insulin secreted by the pancreas or a reduction in the biologic effectiveness of the insulin secreted.
Facts � According to the
2017 Diabetes Report Card, the rates of new cases of diabetes among adults living in the U.S. has decreased, and the rates of new cases among children and adolescents has increased.1
� Diabetes is the seventh leading cause of death in the United States.2
Read more online.
1 Diabetes Report Card. CDC. https://www.cdc.gov/diabetes/library/reports/reportcard.html
2 Diabetes: What is it? https://www.cdc.gov/diabetes/diabetesatwork/pdfs/DiabetesWhatIsIt.pdf
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Wellness center
Amerigroup District of Columbia, Inc. has a new wellness center introducing a member-facing space that will offer classes and health education to support members’ wellness goals. It’s an engaging space for fitness classes, cooking demos, disease management groups, case management support and more. It is not a clinical space for patient care.
Important updates for the wellness center opening: � The wellness center is now complete. � Classes will begin in late January 2019 with a smoking
cessation program hosted by Breathe DC. Please contact Jasmin Saville at 202-548-6700 or email [email protected] for further details or to refer a member.
� The wellness center’s grand opening is tentatively scheduled for February 2019. More details to come when available.
What will the wellness center offer? � All Amerigroup members get free enrollment access
to myStrength™. This is an app that offers safe and secure resources to help improve mood and resilience. You can refer members to https://bh.mystrength.com/myamerigroupdc for help with managing their mental wellness.
� Amerigroup still has a few remaining vouchers for GED testing fees. Please refer interested members to Jasmin Saville at 202-548-6700 or [email protected] as soon as possible. Vouchers expire May 2019.
� Amerigroup has partnered with Relias Learning, LLC, to offer free internet-based continuing education for our providers. We developed a customized training website to provide free mandated and professional growth training.
What if I need assistance?For more information about this communication or to register for a course, please email [email protected]
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My Diverse Patients — a website to support your diverse patients
While there’s no single, easy answer to the issue of health care disparities, the vision of My Diverse Patients is to harness the power of data and identify ways to bridge gaps often experienced by diverse populations.
We’ve heard it all our lives: In order to be fair, you should treat everybody the same. But the challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.
The reality is that burden of illness, premature death and disability disproportionately affects certain populations.1 My Diverse Patients features robust educational resources to help support you in addressing these disparities, such as:
� Continuing medical education about disparities, potential contributing factors and opportunities for you to enhance care.
� Real life stories about diverse patients and the unique challenges they face. � Tips and techniques for working with diverse patients to promote improvement in health outcomes.
Accelerate your journey to becoming your patients’ trusted health care partner by visiting https://mydiversepatients.com today. You may also access the site with the QR code provided.
1 Centers for Disease Control and Prevention. (2013, Nov 22). CDC Health Disparities and Inequalities Report — United States, 2013. Morbidity and Mortality Weekly Report. Vol 62 (Suppl 3); p3.
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“ ”The challenge is that everybody is not the same — and these differences can lead to critical disparities not only in how patients access health care, but in their outcomes as well.
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Medical Policies and Clinical Utilization Management Guidelines update
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Note: � Effective November 1, 2018, AIM Specialty Health® (AIM) Musculoskeletal Level of Care Guidelines, Sleep
Study Guidelines and Radiology Guidelines will be used for clinical reviews. � When requesting services for a patient (including medical procedures and medications), the Precertification
Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.
To search for specific policies or guidelines, visit https://medicalpolicies.amerigroup.com/am_search.html.
Medical Policies On July 26, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved several Medical Policies applicable to Amerigroup District of Columbia, Inc. The effective date of these Medical Policies is February 9, 2019. View the full update online for a list of the policies.
Clinical UM Guidelines On July 26, 2018, the MPTAC approved several Clinical UM Guidelines applicable to Amerigroup. View the full update online for a list of the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018. The effective date of these Clinical UM Guidelines is February 9, 2019.
Read more online.
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New specialty pharmacy medical step therapy requirements
Effective for dates of service on and after May 1, 2019, the specialty pharmacy drugs and corresponding codes from current clinical criteria noted below will be included in our medical step therapy precertification review process. Step therapy review applies upon precertification initiation or renewal in addition to the current medical necessity review (as is done currently).
The clinical criteria below have been updated to include the requirement of a preferred agent effective May 1, 2019.
Clinical criteria Preferred drug Nonpreferred drugING-CC-0001 Retacrit (Q5106) Procrit (J0885)ING-CC-0002 Zarxio (Q5101) Neupogen (J1442), Granix (J1447) and Nivestym (Q5110)
The clinical criteria is publicly available on our provider website. Visit www.anthem.com/pharmacyinformation/clinicalcriteria to search for specific clinical criteria.DC-NL-0105-18
Introducing a new clinical criteria web page for injectable, infused or implanted drugs covered under the medical benefit
Beginning March 1, 2019, providers will be able to view the Clinical Criteria website to review clinical criteria for all injectable, infused or implanted prescription drugs.
This new website will provide the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These clinical criteria documents are not yet being used for clinical reviews, but are available to providers for familiarization of the new location and formatting.
Once finalized, providers will be notified prior to implementation of clinical criteria documents. Injectable oncology drug clinical criteria will not be posted on this website until mid-2019. Until implementation, providers should continue to access the clinical criteria for medications covered under the medical benefit through the standard process.
If you have questions or feedback, please email [email protected]
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Medical necessity review for appropriate level of care
Effective March 1, 2019, certain service requests for District of Columbia Healthy Families Program (DCHFP) members will require medical necessity review for level of care. This includes requests for certain procedures currently reimbursed in the inpatient setting (e.g., services corresponding to codes found on the CMS Inpatient Only [IPO] List).
Certain services that have historically been authorized in the acute inpatient setting may be clinically appropriate for an alternate level of care. For example, while codes for services are listed on the CMS IPO List (a list developed for use in Medicare and not
Medicaid managed care), the corresponding services may be appropriate for an alternate level of care. When a request is submitted for a service that may be appropriate for a level of care other than acute inpatient, Amerigroup District of Columbia, Inc. will review the procedure for medical necessity and apply medical necessity criteria to determine if inpatient level of care is medically necessary.
To review for appropriate level of care, Amerigroup will use the applicable MCG® Care Guidelines (which may include customizations specific to Amerigroup), applicable Amerigroup Clinical Utilization Management (UM) Guidelines or AIM Specialty Health® (AIM) guidelines. If medically necessary criteria for the procedure are met, the procedure will be approved. If inpatient level of care is requested but medical necessity criteria for acute inpatient care are not met, the request for inpatient level of care will be denied. A modified approval/denial letter will be issued accordingly.
To review the list of services and service categories that currently require prior authorization (PA), visit the provider website. For further clarification regarding whether a specific code or service requires PA, access the Precertification Lookup Tool.
The list of services requiring PA will be updated as neededRegardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based upon medical necessity, we encourage providers to review the corresponding medical necessity criteria prior to rendering nonemergent services.
Amerigroup Clinical UM Guidelines and Medical Policies can be found on the provider website. The specific MCG Care Guidelines used to make a determination can be provided upon request. You may also view AIM guidelines using the AIM Guidelines link on the provider site.
Providers are responsible for verifying eligibility and benefits for DCHFP members before providing services. Excluding emergencies, failure to obtain PA for the services and level of care requiring PA may result in a denial of reimbursement.
Read more online.DC-NL-0075-18
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Access patient-specific drug benefit information through electronic medical records
Providers can access real-time, patient-specific prescription drug benefit information at the point of care. It is part of the e-prescribing process, and is located within a provider’s electronic medical record (EMR) system.
This functionality helps providers determine prescription coverage quicker by sharing information about patient drug cost, formulary and coverage alerts such as prior authorization before sending a prescription to the pharmacy. This information can help providers proactively identify barriers to medication compliance. For example, if a medication prior authorization for the member, alternatives can be discussed prior to the patient leaving the provider’s office.
Providers can find the following patient-specific prescription benefit information within their EMR system:
� Formulary status of selected medication
� Pricing of medication at a retail and mail-order pharmacy
� Formulary alternatives � Coverage alerts such as prior
authorization, step therapy, quantity limits, age limits, etc.
Providers should contact their Information Technology (IT) department or EMR system customer support with questions regarding access to real-time prescription drug benefit functionality. Upgrades to EMR software may be required.DC-NL-0108-18
New Mother Postpartum Visit Schedule
The routine postpartum care visit is an important part of overall pregnancy care and is also an important HEDIS® quality indicator. Routine postpartum care should occur 21-56 days after delivery. Depending on the clinical and psychosocial needs of the mother, earlier visits are appropriate (e.g., for the management of hypertension, postoperative care, depression or diabetes). The goals of the postpartum visit are to assess
the mental and physical health of the mother, evaluate mother infant bonding and breastfeeding, and discuss family planning options. Please use our table when scheduling routine postpartum visits for new mothers.
Read more online.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).DCPEC-0675-18
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Physical and occupational therapy reviews
Effective January 1, 2019, Amerigroup District of Columbia, Inc. will transition the management of physical therapy (PT) and occupational therapy (OT) medical necessity reviews from OrthoNet LLC (OrthoNet), to the Amerigroup Utilization Management (UM) team.
What this means to meBeginning January 1, 2019, PT and OT treatment requests for members 21 and over must be reviewed by Amerigroup for prior authorization (PA). You may request PA by submitting complete clinical information to Amerigroup:
� By fax at 1-844-495-4421. � By visiting https://www.availity.com to access the Interactive Care Reviewer PA
tool.
Requests submitted with incomplete clinical information may result in a denial. The initial PT and OT evaluation does not require PA, but subsequent treatments will. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool at https://www.availity.com.
What is the impact of this change? Amerigroup will use our Medical Policies and Clinical UM Guidelines to determine medical necessity for the requested therapies. You may access these policies and guidelines at https://medicalpolicies.amerigroup.com/am_search.html.
Are there any other changes related to PA by Amerigroup?No, Amerigroup will continue to require that PT and OT be provided in a freestanding office setting unless there is a special reason for the service to be provided in a hospital setting. For the most up-to-date list of participating freestanding PT and OT providers, use the referral directory at https://providers.amerigroup.com/DC.
For services that are scheduled on January 1, 2019, or after, physicians must contact Amerigroup to obtain PA for services. Providers are strongly encouraged to verify that a PA has been obtained before scheduling and performing services. Beginning December 17, 2018, providers will be able to contact Amerigroup for PA for services to take place on January 1, 2019, or after.
PA requests sent directly to OrthoNet on January 1, 2019, or after will delay the medical necessity determination.DCPEC-0640-18
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Prior authorization update for 17 Alpha-hydroxyprogesterone caproate/Makena®
Effective December 10, 2018, prior authorization will not be required for the following medications:
� Hydroxyprogesterone 1.25 G/5 ML
� Hydroxyprogesterone capsule powder
� Hydroxyprogesterone 250 MG/1 ML (1 ML and 5 ML VIAL)
� Makena 250 MG/1 ML (1 ML and 5 ML VIAL)
� Makena 275 MG/1.1 ML autoinjection
This change applies to Amerigroup District of Columbia, Inc. members enrolled in the District of Columbia Healthy Families Program, Alliance and the Immigrant Children’s Program.
Our Preferred Drug List is located on the provider website at https://providers.amerigroup.com/DC > Pharmacy. Additional information about resources and programs for pregnant mothers is also accessible on the provider website.
Amerigroup appreciates your partnership in supporting healthy outcomes for mothers and babies.DCPEC-0681-18
Prior Preterm Pregnancy Program
To support your efforts in preventing preterm delivery in high-risk pregnant women, Amerigroup District of Columbia, Inc. is launching a program to ensure providers are aware of members who may benefit from administration of 17 alpha-hydroxyprogesterone caproate (17P). Through this program, you will receive an alert listing members on your panel identified through our high-risk screening survey as potential candidates for 17P.
If you wish to prescribe 17P for your patient, we offer the following guidance on how you may obtain 17P for delivery and administration:
� For office administration of 17P, no prior authorization (PA) is required:
� Fax the prescription and a copy of the member’s ID card to Accredo Specialty Pharmacy at 1-800-824-2642 or call in the prescription to 1-800-870-6419.
� Accredo needs to know where to ship the medication. The member will be contacted by Accredo for verification of delivery before the medication is shipped.
� If the member misses Accredo’s call, please refer them to Accredo Customer Support at 1-800-870-6419.
Preterm birth (delivery before 37 weeks and zero/seven days of gestation) is a leading cause of infant morbidity and mortality in the United States. For women who have had a spontaneous preterm delivery, the risk for preterm delivery in subsequent pregnancies is 1.5-2 times higher. For pregnant women with a singleton pregnancy and a history of spontaneous preterm delivery, 17P can reduce the risk of preterm birth by approximately 30 percent. The U.S. Food and Drug Administration approved hydroxyprogesterone caproate injections to reduce the risk of preterm delivery in pregnant women with a history of prior preterm birth. As with any drug, there are risks that may outweigh these benefits.
If you have questions about this communication, please contact Provider Services at 1-800-454-3730 or an Amerigroup obstetric case manager at 1-800-600-4441.DC-NL-0111-18
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Reimbursement Policy
Policy Update Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service (Policy 06-003, effective 04/01/2019)
The Modifier 25 reimbursement policy for Amerigroup District of Columbia, Inc. provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective April 1, 2019, Amerigroup does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period).
For additional information, refer to the Modifier 25 reimbursement policy at https://providers.amerigroup.com/DC > Quick Tools > Reimbursement Policies > District of Columbia > Coding.DC-NL-0115-19